1. The Great Gas Leak Incident of 2007
LABS: Tip of the month…
Be prepared for unexpected situations!
But if it’s unexpected, how will I know to prepare for it?
Learn from the experiences of others
Case in point…
The Great Gas Leak
Incident of 2007

2. Our lab uses flammable gas with our instrumentation
The instrument room is locked, well ventilated, and equipped with a flammable gas monitor with local and remote alarm
Well-trained personnel follow SOP for changing tanks as part of everyday routine
Ensure gas tank is properly secured
Shut gas flow off at the tank valve
Loosen gas hose fitting (non-sparking wrench)
Unscrew fitting by hand & remove gas hose
Secure cylinder cap on gas cylinder
Label cylinder EMPTY to ensure
pick-up by vendor

3. What could
possibly
go wrong?!

4. Shut gas flow off at the tank valve
Loosen gas hose fitting with spark-resistant wrench
Unscrew fitting by hand & remove gas hose
Secure cylinder cap on gas cylinder
Label cylinder EMPTY to ensure pick-up by vendor
Ensure gas tank is properly secured
Shut gas flow off at the tank valve
Loosen gas hose fitting with spark-resistant wrench
Unscrew fitting by hand & remove gas hose
Secure cylinder cap on gas cylinder
Label cylinder EMPTY to ensure pick-up by vendor
Ensure gas tank is properly secured
Shut gas flow off at the tank valve
Loosen gas hose fitting with spark-resistant wrench
Unscrew fitting by hand & remove gas hose
Secure cylinder cap on gas cylinder
Label cylinder EMPTY to ensure pick-up by vendor

5. Shut gas flow off at the tank valve
Ensure gas tank is properly secured
Loosen gas hose fitting with spark-resistant wrench
Unscrew fitting by hand & remove gas hose
Secure cylinder cap on gas cylinder
Label cylinder EMPTY to ensure pick-up by vendor

6. Shut gas flow off at the tank valve
Tank valve was turned by several rotations in the proper direction
When it would no longer turn, gas flow was assumed off, so moved on to loosening the gas hose fitting
However, the valve had actually
jammed only about half-way
closed, so the gas flow had
NOT been closed-off

7. After a couple turns with the wrench, the gas fitting snapped loose with a jarring “POP” and a white cloud of pressurized hydrogen gas began spraying from the loose connection with a deafening hiss
(SURPRISE & PANIC LED TO POOR CHOICES)
Unable to re-tighten the connection, the individual left the instrument room to get help from colleagues, both of which tried to further close the tank valve but failed
(NO ATTEMPT MADE AT RE-TIGHTENING GAS HOSE)
The group called Operations, reported an uncontrolled hydrogen leak, requested help, and then hung up to deal with the problem
(OPERATIONS NOT GIVEN ALL THE DETAILS OF THE SITUATION)
Operations immediately dispatched a technician who
retightened the gas hose fitting onto the tank, stopping
the gas leak – crisis averted – all was well…
Not having been given all of the details, Operations had
to assume the worst and contacted the Boston Fire
Department to report the leak – BFD notified BPD
Evacuation of Bldg 1 & 2
Shut down of Huntington Ave & Green “E” Line
Fire & Police Chief call Jeremy to “chat”

8. How could this
have been
prevented
or mitigated?

9. How could this have been prevented or mitigated?
SURPRISE & PANIC LED TO POOR CHOICES
As part of training, any and all potential adverse situations related to a protocol should be identified and discussed, as well as the proper way to deal with the situation should they arise.
Drills should be run periodically so workers can learn to respond to problems in real time where they will actually occur.
Preparation will allow individuals to remain calm and be able to make the proper choices to handle the situation.
NO ATTEMPT MADE AT RE-TIGHTENING GAS HOSE
Proper training would likely have prepared the RAs to recognize that retightening the gas hose was a viable alternative to further closing the tank valve.
OPERATIONS NOT GIVEN ALL THE DETAILS OF THE SITUATION
During an emergency, Operations should be provided with
all of the details needed to make appropriate decisions
regarding how to handle a situation
The lab should have worked with Operations BEFORE
discuss all potential adverse situations
establish SOPs to follow in event of a leak

10. Thank you! Good from the bad Take home messages
Lab staff training expanded to dealing with adverse outcomes
Worked with Operations to develop SOPs for dealing with flammable gas leaks in this space
Preventive engineering safeguards proven effective – despite the leak the room’s ventilation system kept the level of hydrogen in air at less then 10% of the LEL
Take home messages
Consider all possible adverse situations in all aspects of work
Take all possible measures to prevent them from happening
Develop SOPs and best practices for dealing with these
Train everyone that may play a role on what to do
RAs performing the protocol / using the instrument
RAs present in the space
Those who respond to the adverse situation
Thank you!